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We describe an uncommon clinical presentation of caudal duplication syndrome and features of caudal regression syndrome in a female infant with complex urogenital and colorectal duplication associated with lipomyleomeningocele and left lower limb hypoplasia. A staged surgical treatment plan was carried out to maintain fecal and urine continence, potential fertility, and cosmetic appearance.

Bile duct lesions with leakage and stenosis can occur after open or laparoscopic cholecystectomy. Multiple factors are involved either related to the patient or external due to technical equipment or surgeon. Bismuth classification is generally accepted. The aim is to restore the bile duct and to prevent short-term and long-term complications such as biliary fistula, intra-abdominal abscess, biliary stricture, recurrent cholangitis, and secondary biliary cirrhosis. Endoscopic therapy with biliary sphincterotomy alone or with the additional placement of a biliary/nasobiliary stent drainage is recommended. Stenting should be avoided if complete strictures exist or a circumferential resection of the duct. Endotherapy can be considered a sensible option and should be the main-stay treatment in these patients but one must keep in mind it is costly and is usually practiced by experienced teams in tertiary centers. The purpose of our paper is to exemplify this complication which is inherently rare, to highlight the diagnostic and treatment tools with minimal long-term sequelae.

Although the standard treatment for ovarian carcinoma with peritoneal metastases is systemic chemotherapy alone or systemic chemotherapy with debulking surgery, a new technique gains more ground: a combination of hipertermic intraperitoneal chemotherapy (HIPEC) and optimal cytoreduction surgery. The proof is mounting regar-ding the benefi ts of HIPEC for patients with metastatic ovarian carcinoma but it still lacks a standard protocol of use. It has increased costs, and incomplete data regarding its safety. Due to these reasons, it is still considered an alternative treatment. Our study aimed to evaluate the published literature regarding this technique from the point of view of safety and effi cacy when compared with the standard of care treatment.

Cytoreductive surgery and HIPEC have become de pillars of treatment in advanced, metastatic colorectal cancer. This state of evolution of the disease was considered terminal just a few years ago. It has been demonstrated that by combining these therapies in selected patients one can increase survival time. Once this has been obtained to some length modern studies have been focused on the quality of life, safety, and how this time interval can be increased. We have reviewed the most important prospective, randomized clinical trials regarding HIPEC and peritoneal carcinomatosis. The technique, complications, principles of action, and evolution through time of HIPEC have been addressed and covered. Special consideration had been given to the correlation between the carcinomatosis index and HIPEC. HIPEC with maximal cytoreduction can be considered a curative procedure only in strictly selected patients diagnosed with colorectal cancer and peritoneal carcinomatosis. Although it has been present in the medical field for almost 30 years, it is not wide-spread due to the high costs of implementation and the requirement of highly specialized surgical and medical teams. As technology evolves, the costs can be decreased and HIPEC should be largely available in oncological centers since the foundation of implementation is solid and the fact that clear benefits although small have been demonstrated. Taking into account all of the above, HIPEC should not be considered a standard treatment at present and should only be performed in experienced centers. The correct selection of patients is critical to the success of this procedure. Maximum cytoreduction should only be performed if the carcinomatosis index allows.

The liver is one of the most affected organs in abdominal trauma mostly because of its considerable dimensions, the fragility of the liver parenchyma. We present the case of a 29-year-old patient who sustained an abdominal trauma after an accidental fall from a 3 m height. The patient tested positive at RT-PCR for SARS-CoV-2 at admission, without any symptoms of viral infection. The emergency CT scan revealed a blunt liver trauma with an expanding hematoma (grade III). The patient was initially hemodynamically stable but shortly after admission became unstable and required surgical treatment that initially consisted of damage control and liver packing. Reintervention was decided 36 hours later, after reevaluation unpacking and hepatorrhaphy were done. The postoperative evolution was uneventful. The case indicated the importance of continuous monitoring of the traumatic patient. In liver trauma, hemodynamic instability guarantees an emergency laparotomy. The time of operations in trauma patients with SARS-CoV-2 must be reduced to the maximum both as an objective of damage control and also to minimize the risk of contagion.

Cancer related-pain causes a negative psychosocial and physical impact on patients’ lives. The purpose of this review was to investigate the current strategies forcancer paintreatment. Material and Methods:We conducted a PubMed search of the literature published from 2018 to 2020, and details were extracted from the articles with adequate study quality. Discussion: Of 63 titles, 19 studies were selected and used in review. Conclu-sions: This review article focuses on the noveltreatments available for cancer pain management.

The Covid-19 pandemic changed certain social habits and practices. The pandemic also changed the profile of polytrauma patients who presented in the emergency room. The etiology of polytraumas has undergone changes in the context of social distancing. While road accidents, falls and physical assaults, including gunshot trauma on the streets have decreased, we are confronting with an alarming increase in domestic violence. We analyzed the etiology of polytraumas from a period of 3 months that overlapped with the pandemic and compared it with the similar periods of the previous 3 years. We found an increase of about 4 times the incidence of physical aggression through domestic violence.

Brachial mycotic pseudoaneurysms (BMPA) are a rare complication of infective endocarditis (IE), but potentially could be a limb-threatening condition. We present the case of a 38-year-old male referred to our department, complaining of the sudden onset of a painful pulsatile mass 5 x 10 cm in the right antecubital fossa that slowly progressed over time. Two years before this, he underwent aortic and mitral valve replacement with mechanical prosthetic valves and tricuspid annuloplasty for IE with methicillin-susceptible Staphylococcus aureus after a six-week course of intravenous antibiotherapy with oxacillin. Clinical examination of the right upper limb revealed a pulsatile and compressible mass with a normal temperature and without other clinical signs of inflammation. Pulse of the axillary artery, brachial and radial arteries were palpable. He was diagnosed by Doppler ultrasonography and digital subtraction angiography with BMPA. Furthermore, transesophageal echocardiography (TEE) revealed normal function of the aortic and mitral prosthetic valve with no signs of prosthetic valve endocarditis and no feature of congestive heart failure. Considering these clinical findings, surgical treatment was planned. He underwent re-section of the brachial pseudoaneurysm and arterial reconstruction. One year after the pseudoaneurysm resection, evolution was excellent. This manuscript presents this rare, uncommon complication after IE and also reviews the available surgical management strategies for this pathology.

Due to its anatomical position, traumatic lesions of the pancreas are rare and difficult to diagnose. Diagnosis time is paramount as an increase in duration translates into an increase in morbidity and mortality. Duct lesions are hard to identify on CT, ERCP being the investigation of choice but it is difficult to obtain as it requires highly specialized staff and equipment. Intraoperative macroscopic and palpatory evaluation of the pancreas in a trauma patient should be elective no matter what other lesions are present. The treatment is mainly dictated by this evaluation and is defined as it follows: stage I and II usually require a conservative approach; stage III, IV, and V usually imply resection of the pancreas although recent advances in conservative management have been made through ERCP and pancreatic duct stenting. In these stages, intraoperative evaluation should ensure the ampulla is intact if the head of the pancreas is not resected. Serum amylase and lipase levels do not offer a concrete direction towards a pancreatic lesion. Currently, there is no standard surgical treatment for these stages thus making intraoperative evaluation mandatory. One must remember that post-traumatic pancreatitis exists, which becomes apparent days after the accident.

Mesenteric lesions in abdominal trauma are encountered in 3% of the cases. Diagnosis of these lesions is difficult, which translates into important delays until surgery that affects patient survival. The short-term consequences of mesenteric lesions translate in bowel ischemia or important blood loss. If a lesion is confirmed after imagistic investigations, one must have complete knowledge of the anatomy and the particular distribution of the main arterial and venous trunks to predict the region of the small bowel that will have to be observed or resected if surgery is required. The aim of our study was to demonstrate this particular distribution of blood vessels through cadaver dissection and to note the resources available to diagnose such lesions.

Increase in the number of patients with chronic kidney disease (CKD) calls for improved management of these patients. In stage 5 CKD, when the initiation of renal replacement therapy (RRT) becomes necessary, there is an increase in the infection risk of the patients and immunological tests for hepatitis C virus (HCV) detection turn positive at an alarmingly higher rate compared to general population. With the introduction into clinical practice of diagnostic tests, the increased prevalence of HCV among CKD patients has been known since the 1990s. Also, the negative impacts of HCV infection on CKD evolution as well as the unfavorable evolution of grafts received by HCV infected patients are known. Chronic hemodialysis patients are a category of patients whose risk of HCV infection is substantial. Currently, in the hemodialysis centers, at the base of the transmission of HCV infection there are a multitude of factors. Infection with HCV has a different impact on patient with end-stage renal disease (ESRD). Comorbidities in this case have significant sources of mortality and morbidity. It was proven that the post transplantations problems were prevented and mortality was reduced for patients who were diagnosed with HCV and in whom the infection was treated before the kidney transplant (KT). Consequently, early detection of the infection and the application of specific treatment has a considerable impact on the outcome of the patients. Another important component of the management of HCV infection in the chronic hemodialysis patients is the prevention of the infection transmission by applying specific methods.

Lipomas are the most common type of soft tissue tumors. They mainly are located in subcutaneous tissue in the body, including the heart. The cardiac location of lipomas is rare, mostly asymptomatic, and can cause life-threatening complications by rapid growth. The clinical symptoms, when present, occur in evolution with the growth in size, depending upon the location and degree of invasion in the endocardium. We present the case of a 63-year-old male patient with a large intrapericardial lipoma with an unusual location, originating from the left atrial roof. The initial symptoms of the patient were shortness of breath, dizziness, and mild dyspnea. Transthoracic echocardiography (TTE) was the first line diagnosis method, followed by computed tomography (CT); both showed a large posterior intrapericardial mass. Resection of a 12/8/5 cm lipomatous tumor mass was performed via median sternotomy, under cardiopulmonary bypass (CPB) on the beating heart. Histopathologic examination revealed the presence of diffuse proliferation of large- and medium-sized mature adipocytes consistent with the diagnosis of pericardial lipoma. The patient was discharged at home on the seventh postoperative day, with a marked improvement of his clinical state and effort tolerance. He did not present evidence of recurrence at his 1-year follow up.

Thyroid angiosarcoma (AS) is a specific type of vascular tumor that arises from the endothelial cells, being highly aggressive, with increased recurrence rates and metastasis. It is characterized by positive endothelial markers and co-positive markers for cytokeratins and epithelial membrane antigen. We are describing the case of a 76-year-old patient who presented to the hospital for dyspnea and asthenia. The clinical and paraclinical investigations confirmed the presence of a right large thyroid nodule, which turned out positive at immunostaining for AS. Even if thyroid AS is a rare type of tumor, mainly described in the Alps, one has to take into account that it can evolve in any other regions and should be considered as a differential diagnosis.

Malignant peripheral nerve sheath tumors are a type of soft tissue sarcoma deriving from Schwann cells that usually appear in type 1 neurofibromatosis patients but also sporadically. Tumors frequently interest the nerves in the limbs. They represent a therapeutical challenge due to difficulty of resection and relative radio-resistance and chemo-resistance. The paper aims to describe targeted therapy used in this setting and news concerning the molecular changes that lead to carcinogenesis initiation and promotion. A short selection of literature data was made using PRISMA criteria on this topic. However, due to the rarity and heterogeneity of these tumors, personalized treatment is necessary.

Flail chest in a trauma patient presents itself with a number of problems. The mainstay treatment in the past was analgesia with non-operative observation but due to the increased rate of complications, new treatment modalities have been researched. Chest wall plate fixation has emerged as the go-to solution for these patients but consensus lacks regarding when it should be applied, to what category of trauma patients, which technique and which surgical specialty should be the promoter of this technique. All these problems have arisen due to the lack of large prospective studies. A number of these studies are ongoing with results to be published in the near future. Until then, preliminary data have demonstrated the superiority of plate fixation in flail chest in comparison with the non-operative management.

Introduction: Pelvis fractures that associate bleeding with hemodynamic instability warrant immediate treatment. The therapeutic options in these cases vary from angioembolization to extraperitoneal pelvic packing. Material and method: The P.I.C.O.S guidelines were used to structure the questions and the research topic as to attain clinical validity. The results of the research were filtered in accordance with the PRISMA checklist. Results: 38 papers were identified. After screening, 27 papers were used to complete the analysis. Discussion: Frequently, bleeding has a venous source in the pelvis. In the case of pelvic fractures with hemodynamic instability, extraperitoneal pelvic packing is one of the core treatments but not a stand-alone treatment, as it needs to be coupled with a pro-efficient trauma resuscitation protocol. Its intended use is as a bridge therapy until conclusive investigations regarding the place of bleeding can be obtained. Angiography is recommended if hemodynamic instability exists after pelvic packing and effective hemodynamic resuscitation. Conclusion: Even with all these recent efforts, the wide-use of this therapy is precluded due to the absence of a standardized evaluation of these patients and large multicentric studies.

Introduction. Gastrointestinal stromal tumors (GISTs) represent a rare type of gastrointestinal neoplasms. Resection with negative margins has been established as a mainstay treatment, but laparoscopic resections are still open to debate. Material and method. This retrospective study was conducted at a single institution, with data collected over 2 years (01.01.2017-01.01.2019). The variables examined were age, tumor location with regard to the gastric wall, the results of the intraoperative endoscopy, intraoperative and postoperative complications, the surgical technique, and histopathological reports. Results. We identified 12 relevant cases, of which 8 were females and 4 males. The average tumor diameter was 2.3 cm. The majority of the lesions were located on the anterior gastric wall (8 cases), on the small curvature (2 cases), and in the pyloric region (2 cases). Intraoperative endoscopy was performed successfully in 10 cases in order to identify the lesions and guide the resection. The average operative time was 120 minutes and the average hospital stay was 5 days. The gastric wall with the lesion was resected using an Ultrasonic device, a 2-cm oncological safety margin was preserved. Conclusion. Complete surgical resection independent from the tumor size represents the current optimal treatment. From a surgical point of view, these tumors must be considered malignant and the surgeon must respect principles of oncological surgery. Maintaining tumor integrity at dissection is critical for the patient’s long-term prognosis. Laparoscopic resection independent of the tumor size is feasible.

Introduction. Achalasia is defined as incomplete or even absent relaxation of the lower esophageal sphincter secondary to the chronic degeneration of unspecified etiology of the myenteric nerve plexus. Material and method. The retrospective study extended over 1 year. The collected variables were: age, sex, type of surgical intervention, intraoperative manometry results, and postoperative complications. Results. We identified 8 patients. The mean operative time was 100 minutes. The use of manometry determined an increase in time of 30 to 40 minutes. Manometry was successfully achieved in all cases, although in one case the sensor could not pass through the lower esophagus, so a prior pneumatic dilation was required. Manometry has proven useful during fundoplication as it offers a direct view of the pressure produced when knots set at 12 - 15 mmHg with a length of 4- 5 cm were tightened. Of the 8 patients, 6 required an increase in the length of the resection of the esophagus after the results of the intraoperative manometry were reviewed. Conclusion. In our opinion, after reviewing our experience and the literature data, intraoperative manometry should become a standard procedure in the laparoscopic treatment of achalasia.

Neuroendocrine tumors represent a varied group of neoplasms which have the potential to produce and secrete a wide range of hormones along with other vasoactive substances.The care of these patients involves several specialties including:surgery, oncology, radiotherapy, interventional radiology and nuclear oncology. Despite this large number of options there is currently no consensus on the optimal sequence of these treatment resources for metastatic patients.We present the case of a 24 year women who was diagnosed with a gastric tumor (could not be biopsied) by imagistics and liver metastatsis. A Pean resection with metastasectomy was done. The histopathology study revealed that the gastric tumor was benign ectopic pancreas tissue and the metastases were actualle of neuroendocrine origin. A somatostatin receptor scintigraphy (OctreoScan) was done which revealed the primary tumor in the ileal mesentery which was resected in a secondary intervention. The patient was started on long acting sandostatin with no recurence.

Introduction: An increasing interest exits towards the use of antibiotics in the treatment of uncomplicated acute appendicitis.Discussion: For a long period of time, surgery was the only treatment for acute appendicitis. Due to recent research in the etiology of acute appendicitis which seems to be driven by intraluminal bacterial proliferation, new data suggests that for non-perforated appendicitis confirmed with the help of CT, antibiotics may play a central role in the treatment. As relapse rates amount in some cases to only 5% after antibiotic treament, a discussion is required regarding the risks of interval appendectomy and its use. The debate regarding the optimal antibiotic course is on-going as some surgeons advocate for amoxicillin/clavulanic while others, due to acquired resistance recommend Ertapenem.Conclusion: Selective antibiotic treatment for selected forms of acute appendicitis, uncomplicated without perforation is safe and has a relatively low complication rate. However, certain mentions must be made: surgery must not be delayed if failure of antibiotics exists as it can lead to higher rates of peritonitis. Close clinical surveillance is of utmost importance

Next-generation sequencing (NGS) is a fast and relatively inexpensive method to sequence a large number of genes with crucial importance in cancer medicine. Nowadays, NGS is frequently used in diagnostic and therapeutic decisions in oncology; however, recently, it was demonstrated that only a few cancer sites actually benefit from this assessment. Moreover, the association of a mutant gene with a targeted drug is not always as predicted during in-vitro trials and is often not associated with tumor response. To predict the efficacy of such an association several classification systems have been developed. The present review aims to analyze the most important tumor agnostic treatment trials and assess how they shape selecting cancer patients for NGS. Moreover, it aims to determine how mutation-drug associations can be classified by their targetability and level of evidence of efficacy in non-small-cell lung cancer.

Here, we describe a case of a 61-year-old male patient with acute type A aortic dissection involving the ascending aorta, aortic arch, descending aorta, and the abdominal aorta down to the iliac bifurcation with evidence of left common iliac artery occlusion. Computed tomography angiography revealed progressive dissection into the superior mesenteric artery and left renal artery with no clinical signs of mesenteric ischemia. Emergent ascending aortic reconstruction of the dissected aorta relieves the leg ischemia. On a postoperative day 9, the evolution was complicated by massive right hemothorax. Although the patient was hemodynamically stable after obtaining hemostasis, the patient developed paralytic ileus with a high elevated lactate level. Visceral malperfusion was not detected by exploratory laparotomy. Emergency abdominal aortic angiography revealed superior mesenteric artery intermittent occlusion, successfully treated by stenting implantation.

Background/aim Left ventricular aneurysms are complications following acute myocardial infarction. Left posterior left ventricular aneurysms occurring in a submitral position constitute a minor entity, and those leaving the mitral apparatus intact are extremely rare. Case report Herein, we report the case of a 58-year-old patient with a past medical history of coronary artery disease and myocardial infarction with a giant left posterior left ventricular aneurysm with moderate mitral valve incompetence. Results The patient underwent myocardial revascularization and, through a transaneurysmal approach, successful endoventricular pericardial patch wall reconstruction with no impact on mitral valve competence. Conclusion Whenever the mitral valve is not affected, a trans aneurysmal approach with endoventricular pericardial patch in association with myocardial revascularization represents a safe and reproducible approach with good functional outcomes.

Background/aim Currently, the impact of diabetes mellitus (DM) on rectal cancer patients is complex and just partly elucidated. The purpose of this study was to investigate the impact of diabetes mellitus on rectal cancer patients focusing on tumor differentiation grade, neoadjuvant chemoradiotherapy (NACRT) response, disease-free (DFS) and overall (OS) survival. Patients and methods Our study's population consisted of a group of 53 patients diagnosed with locally advanced rectal cancer, who underwent NACRT, followed by radical oncological surgery. This patient population was further divided into two groups according to diabetes presence. Results Downstaging rates, local control, DFS, and OS were lower in the DM subgroup compared to the non-DM locally advanced rectal cancer patients. Conclusion The presence of DM at the time of diagnosis of locally advanced rectal cancer patients may be a negative predictive factor for response to neoadjuvant therapy, distant metastases, and local recurrences rates.

Despite the development of imagistic methods, the differential diagnosis of a right atrial mass may be difficult to be established, the most common pathologies which should be taken in consideration being represented by thrombus, tumors, prominent crista terminalis, or vegetation of infectious endocarditis. In this study, we present the case of a 63-year-old man with chronic kidney disease, in hemodialysis (HD) with a silicone central venous catheter (CVC) with the incidental transthoracic echocardiography (transthoracic echocardiogram, TTE) finding of a tumoral mass of 35x26 mm in the right atrium (RA), not related with the catheter, which was diagnosed as right atrial myxoma and underwent surgical excision. After reviewing the histopathology probe, the diagnosis of right atrial thrombus was confirmed. In conclusion, differentiating intracardiac right atrial masses (RAMs) could may prove challenging. In our patient, clinical presentation and the preoperative investigations could not differentiate the right atrial thrombus from a myxoma, and only the postoperative histopathology diagnosis was able to guide correct diagnosis.

Thyroid cancer accounts for 1% of all malignancies, and is becoming increasingly common worldwide. The literature reports a prevalence of ~50% of thyroid nodules detected during autopsies in subjects with unknown thyroid pathology. An extended retrospective study of 526 autopsy cases was performed to identify the prevalence of thyroid carcinoma, among various types of thyroid nodules identified incidentally. Tissue samples were taken from thyroid nodules, for investigation of the presence of thyroid carcinoma, along with their macroscopic and microscopic features by means of histopathology and immunohistochemistry (IHC) methods. Histopathological diagnosis of malignancy was found in 51 cases of analyzed thyroid samples. Systematic detailed studies demonstrated that a thyroid gland, apparently normal on macroscopic examination, may be the site of pathological manifestations, sometimes presenting carcinomatous findings. Among thyroid carcinomas, the highest frequency was that of papillary microcarcinomas, which have a long evolution, and are incidentally detected during autopsies. Papillary microcarcinoma is an extremely common incidental finding and the vast majority of these tumors pursue a benign course. Furthermore, it is therefore necessary to create national screening programs for the early detection of thyroid carcinoma.

Paragangliomas are extremely rare neuroendocrine tumors. We report a case of a 44-year-old man with hypertension who presented a tumoral mass located retroperitoneally at the aortic bifurcation which included both the common iliac arteries and the posterior left iliac vein, who experienced an unpredictable intraoperative cardiac arrest with electromechanical dissociation at 5 min after laparotomy. After successful resuscitation and hemodynamic stability, the lesion was fully excised. In the course of tumor manipulation, the patient developed a major hypertensive crisis with peak systolic blood pressure over 280 mmHg. Pathologic examination revealed the presence of diffuse proliferation of large and medium-sized mature adipocytes consistent with paraganglioma diagnosis. The patient was discharged at home on the seventh postoperative day. He did not present evidence of recurrence at the one-year follow-up. In conclusion, paragangliomas can require particular management due to their location but also due to their capacity to discharge substances which might induce life-threatening intraoperative complications.

Renal cell carcinoma (RCC) accounts for over 90% of all renal malignancies, and mainly affects the male population. Obesity and smoking are involved in the pathogenesis of several systemic cancers including RCC. The phosphoinositide 3-kinase (PI3K)/protein kinase B (AKT)/mammalian target of rapamycin (mTOR) signalling pathway regulates cell growth, differentiation, migration, survival, angiogenesis, and metabolism. Growth factors, hormones, cytokine and many extracellular cues activate PI3K/AKT/mTOR. Dysregulation of this molecular pathway is frequently reported in human cancers including RCC and is associated with aggressive development and poor survival rate. mTOR is the master regulator of cell metabolism and growth, and is activated in many pathological processes such as tumour formation, insulin resistance and angiogenesis. mTOR inhibitors are used at present as drug therapy for RCC to inhibit cell proliferation, growth, survival, and the cell cycle. Temsirolimus and everolimus are two mTOR inhibitors that are currently used for the treatment of RCC. Drugs targeting the PI3K/AKT/mTOR signalling pathway may be one of the best therapeutic options for RCC.

Obesity is a worldwide pandemic health issue. Obesity is associated with the pathogenesis of type 2 diabetes, hypertension, dyslipidemia, cardiovascular diseases, cancer, and kidney diseases. This systemic disease can affect the kidneys by two mechanisms: Indirectly through diabetes mellitus (DM) and hypertension and directly through adipokines secreted by adipose tissue. Obesity is a risk factor for chronic kidney disease (CKD), which is associated with an increased risk of morbidity and mortality among the adult population. Increased visceral adipose tissue leads to renal glomerular hyperfiltration and hyperperfusion, which may lead to glomerular hypertrophy, proteinuria, and CKD development. Adipokines are hormones produced by fat tissue. They are involved in energy homeostasis, sugar and fat metabolism, reproduction, immunity, and thermogenesis control. Hormones and cytokines secreted by adipose tissue contribute to the development and progression of CKD. Decreased serum or urinary adiponectin levels are specific in diabetic and non-diabetic CKD patients, while leptin presents increased levels, and both are associated with the development of glomerulopathy. Excessive adipose tissue is associated with inflammation, oxidative stress (OS), insulin resistance and activation of the renin angiotensin-aldosterone system (RAAS). Therefore, adipose tissue dysfunction plays an important role in the development of CKD.

An increasing number of patients require renal replacement therapy through dialysis and renal transplantation. Chronic kidney disease (CKD) affects a large percentage of the world's population and has evolved into a major public health concern. Diabetes mellitus, high blood pressure and a family history of kidney failure are all major risk factors for CKD. Patients in advanced stages of CKD have varying degrees of cardiovascular damage. Comorbidities of these patients, include, on the one hand, hypertension, hyperlipidemia, hyperglycemia, hyperuricemia and, on the other hand, the presence of mineral-bone disorders associated with CKD and chronic inflammation, which contribute to cardiovascular involvement. Acute complications occur quite frequently during dialysis. Among these, the most important are cardiovascular complications, which influence the morbidity and mortality rates of this group of patients. Chronic hemodialysis patients manifest acute cardiovascular complications such as intradialytic hypotension, intradialytic hypertension, arrhythmias, acute coronary syndromes and sudden death. Thus, proper management is extremely important.

As life expectancy increases, a rise in the number of chronically ill patients is observed due to the aging population. Among the various diseases, chronic kidney disease is at present one of the main causes of morbidity and, due to its typical complications, it is also one of the most important causes of mortality in the general population. For these reasons, the understanding of the kidney aging process, its consequences and its adequate management are essential. The judicious use of certain types of drugs, the prevention of episodes of renal injury either by toxic mechanisms or by dehydration are important aspects and are part of the apropriate approach for elderly patients. The most effective treatment of various types of conditions with a negative impact on renal function and for which an increased incidence is known as we age should also be considered. Thus, in the case of elderly patients, in order to protect the kidneys, an integrative approach is recommended, one that includes both elements of prevention and the appropriate treatment of existing diseases.

Hemodialysis is a method for the renal replacement therapy followed by series of acute and chronic complications. Dyselectrolytemia appears in patients undergoing dialysis through mechanisms related to the chronic kidney disease and/or to the dialysis therapy and for this group of patients it is associated with an increase of morbidity and mortality. The dialysate has a standard composition, which can be modified according to the patient's characteristics. During hemodialysis patients are exposed to 18,000-36.000 litres of water/year, and the water purity along with the biochemical composition of the dialysate are essential. The individualization of the dialysis prescription is recommended for each patient and it has an important role in preventing the occurrence of dyselectrolyemia. The individualization of the treatment prescription according to the blood constants of each patient is the prerogative of the nephrologist and the association of the electrolyte imbalances with the patients cardiovascular mortality explains the importance of paying special attention to them.

Background/aim Cardiac papillary fibroelastomas (CPF) are benign tumors, frequently asymptomatic, characterized by a mobile pedunculated mass that arises from the endocardium. When CPF is located in the left ventricle, it may protrude into the left ventricular outflow tract and affect hemodynamics. They are highly thrombogenic, and can also cause some life-threatening events such as cerebral and peripheral embolization. Case report We herein report a case of a 74-year-old female admitted to our center with palpitations and dyspnea on exertion. Her past medical history revealed that she had had a transient ischemic attack 7 months before presentation. Echocardiography and cardiac magnetic resonance imaging revealed an intracardiac mass anchored in the anteroapical interventricular septum without interference with aortic or mitral valve functionality. Surgical resection of the left ventricular mass was performed through the left apical ventriculotomy approach. Histopathological examination of the tumor was suggestive of papillary fibroelastoma. The postoperative course was uneventful. The patient was discharged home on the eighth postoperative day, with no recurrence at 6 months. Conclusion Although left ventricular papillary fibroelastomas are benign tumors, they carry a high risk for embolic complications and therefore surgery should be proposed, the transapical approach being a safe and effective method.

Hepatocellular carcinoma is one of the primary liver malignancies responsible for over a million deaths per year worldwide (approximately 10% of all deaths in the adult age range). The diagnosis of HCC can be difficult and often requires the use of more than one microscopic technique. A retrospective study was performed on a study batch of 42 cases that died of HCC due to metastasis or other secondary complications. Tissue samples were taken in order to investigate the tumour antigenic constellation by means of IHC method using a large variety of antibodies. In situ hybridization was also performed for albumin mRNA to assess the albumin expression in some selected cases. Telomerase activity was investigated using IHC method for the hTERT catalytic subunit. A cocktail of hepatic cytokeratins (CK8, 18) combined with Hep Par-1 and associated to albumin proved to be more powerful than albumin alone in differentiating HCC and increased the value of tumour diagnosis. hTERT expression was proportionally reverse to the tumour degree of differentiation, but was independent from the expression of tumour-proliferating indexes. The heterogeneity of the antigenic constellation in hepatocellular carcinoma suggests an antigenic mosaicism, which can be expressed a synchronous or metachronous manner, depending on the tumour degree of differentiation.

Iatrogenic iliac arteriovenous fistula (IAVF) is an extremely rare complication after lumbar discectomy surgery (LDS), with potentially life-threatening consequences. An IAVF results from the close anatomic relation between the iliac vessels and the last lumbar vertebrae and the corresponding discs. We report the case of a 45-year-old woman who developed a large right IAVF 3 years after L4-L5-S1 laminectomy. The arteriovenous fistula (AVF) was successfully treated with an endovascular technique using a WALLSTENT self-expanding stent. The postoperative period was uneventful, and the patient was discharged from the hospital in good general condition on the third postoperative day.

Sexual dysfunction following surgery for rectal cancer may be frequent and often severe. The aim of the present study is to evaluate the postoperative incidence of this complication and its severity. The current study is a retrospective study in which consecutive patients with rectal tumors, regardless of location (upper, middle or lower) were enrolled during a 1 year period in the General Surgery Clinic of the Emergency Clinical Hospital Prof. Dr. Agrippa Ionescu, Hospital, Bucharest. The patient files, paraclinical investigations, operative protocols, and histopathological bulletins were reviewed and data regarding age, gender, date of diagnosis, medical treatment administered including neoadjuvant therapy and reinterventions were collected. The IIEF-5 type questionnaires were used to assess sexual function at 6 months. We identified a number of 30 patients with amedian age of 60 years. All the patients were operated via open approach. Total mesorectal resection (TME) was practiced in 18 cases. Mean period follow-up was 10 months. Perioperative mortality was 0. There was no recurrence 1 year after surgery. Ten patients benefited from neoadjuvant radiotherapy. Rate of erectile dysfunction was 80%. The rate of ejaculation dysfunction was 70%. Patients operated for rectal cancer via an open approach showed severe sexual dysfunctions (SD). These complications affect the patient’s quality of life and need a multidisciplinary approach towards a better understanding of this problem by both the medical staff and the patient.

Multiple primary malignancies have an increasing incidence in the general population due to better diagnostic tools and the increased life expectancy. However, synchronous lesions are still rare and have a rate which varies between 0,17 and 0,69%. Second primary tumours usually develop after some time from the first cancer diagnosis. Although there is an arsenal of therapeutical options – the order and priority of the therapeutic choices are debatable and need to be tailored to every patient. The present paper illustrates the case of a 40 years old woman who presented to the emergency department with diffuse abdominal pain, nausea and bloating. The patient had done a fine needle biopsy of a suspicious lump in her right breast one week before the presentation and had no other relevant medical history. The CT scan revealed intraperitoneal free liquid with a paracolic mass at the rectosigmoid junction. The surgical team decided to perform an exploratory laparoscopy. At exploration, the mass was intensely adherent to the uterus and fixed to the pelvis. Conversion to laparotomy and extemporaneous exam of the mass were undertaken, which revealed adenocarcinoma. En-bloc rectosigmoidian resection with hysterectomy and bilateral adnexectomy. The histopathology report staged the tumour as pT4N2M0 adenocarcinoma. Breast biopsy pathology report revealed no special type (NST) carcinoma, with luminal B breast cancer on immunohistochemistry. Clinical staging of the breast was cT1N0. After discussion of the case in the multidisciplinary team, it was decided for Madden mastectomy with axillary lymphadenectomy. Breast reconstruction with retropectoral expander was done in the same operating procedure. Post-mastectomy pathology report revealed pT1N0 and no metastases were present at standard imaging. The immunohistochemical profile of the resected breast tumour proved to be Luminal A. Adjuvant therapy consisted in chemoradiation for the rectum. The breast neoplasia was treated with tamoxifen as adjuvant therapy. Synchronous primary neoplasia exists and even if they have a low incidence once identified their treatment requires particular treatment for each case. A multidisciplinary approach is essential.

Basal Cell Carcinoma is the most common human malignant neoplasm. Vulvar basal cell carcinoma is rare, accounting for less than 5% of all vulvar neoplasms. Vulvar basal cell carcinomas are usually diagnosed late because they are often asymptomatic and tend to grow at slow rates. They are usually diagnosed late because they are often asymptomatic. However, these tumours may appear in areas which are normally covered with ultraviolet light. We present the case of a 60 years old woman diagnosed with invasive breast cancer for which she underwent surgery followed by chemotherapy and radiotherapy. The patient presented to our department with an ulcerated vulvar lesion. On inspection, the tumour measured 3/2 cm and was located on the left labium majus. The biopsy confirmed the diagnosis of vulvar basal cell carcinoma and a wide local excision was performed with no relapse at one year. In conclusion, early detection of BCC’s is critical to allow complete surgical cure so any abnormality on the vulva should be biopsied. A wide safety margin of 1cm should be achieved when resecting the tumour and the physician should keep in mind that the BCC’s of the vulva has a high recurrence rate. Previous chemotherapy is not associated with this type of non-melanoma skin cancer.

Objective. The purpose of this paper is to review the current concepts in the literature regarding the beneficial effects of adjuvant surgery after concurrent radio-chemotherapy for locally advanced cervical cancer. Method. Research of the literature was performed using PubMed databases in order to find articles relevant to the central topic. The PICOS criteria were used to filter the results. The paper was then structured according to the PRISMA guideline. Results. 50 individual papers were analyzed and sorted according to their relevance for the topic. 18 were classified as relevant. There was little agreement as to how beneficial adjuvant hysterectomy is in locally advanced cervical cancer after chemoradiotherapy. Some articles concluded that patients with a total clinical response after initial treatment might have superior progression-free survival and overall survival after surgery. 2 articles underlined the importance of accurate restaging after primary treatment. The lack of benefit for surgery in patients with bulky disease or persistent adenopathies was agreed upon in all cases. Conclusions. The decision for adjuvant hysterectomy with or without lymphadenectomy is a controversial one and has to be personalized and taken in a multidisciplinary team.

Microsatellite instability (MSI) is a feature of colorectal tumors that develops as a result of inactivation of the DNA mismatch repair system. It is found in about 15% of all colorectal cancers and is an important prognostic molecular marker when assessing patients with colorectal cancer. It can influence prognosis and treatment decisions in both the advanced and early stages. Although in early stages this marker suggests a favorable prognosis and presents an important argument against adjuvant treatment in stage II disease, in metastatic stages it no longer associated with such an optimistic outcome. The present trial is a prospective, single-center study which included 122 colorectal cancer patients who were tested for MSI using immunohistochemistry. The trial included patients with stage II to IV colorectal cancer, treated in the Prof. Dr. Agrippa Ionescu Emergency Hospital, Bucharest, Romania. Follow-up data were collected during a 24-month period. The study attempted to determine whether differences exist in overall survival for MSI (microsatellite instability) vs. MSS (microsatellite stable) colorectal cancer and to ascertain whether sex of the patient influences prognosis in MSI patients, irrespective of stage or treatment. Results demonstrated no significant differences in survival for MSI vs MSS colorectal patients, and patients’ gender proved not to influence the outcome in MSI patients.

The incidence of thyroid cancer is significantly different between male and female patients. Thyroid cancer is also the only form of cancer where age can be considered a staging variable. Identifying biological prognostic factors such as age or sex is important as it helps select an optimal personalized therapy. The present analysis is an observational, prospective study that enrolled all patients with thyroid disease who were operated upon at a single center. The study aimed to determine the most frequent age at presentation, the predominance of one sex over the other, the incidence of malignant thyroid disease, and the relative risk for each sex to develop thyroid carcinoma. The incidence of thyroid carcinoma was higher for women than for men, with a higher relative risk in the female subgroup. Incidence was also highest in the 50-60-year-old group. Given that studies show better survival for women and for younger patients, even when presenting with advanced disease, compared with older, male patients, such prognostic indicators should be a factor in the treatment decision.

Cardiovascular disease is the main cause of morbidity and mortality in end-stage renal disease (ESRD) patients. Recent population based epidemiological studies demonstrated a correlation between reduced renal function and risk for all causes and cardiovascular mortality, 50% of patients dying before the commencement of renal replacement therapy. Vascular calcifications (VC) and arterial stiffness are major contributors to cardiovascular disease and are independent predictors of cardiovascular mortality in ESRD patients. Scarce information is available on the risk factors and prognosis of predialysis patients with VC. The aim of this study was to evaluate the contribution of traditional and uremia related risk factors to abdominal aortic calcification in predialysis patients. A single center, retrospective study was performed on 305 adult patients monitored at the Bucharest University Emergency Hospital for at least 6 months. Our study reports an increased incidence of VC in predialysis chronic kidney disease (CKD) patients, higher in those with advanced age, history of cardiovascular disease, osteoporosis, and declining renal function.

Introduction: Over time, the management of rectal cancer has undoubtedly evolved with the use of neoadjuvant radiochemotherapy. Material and method: The P.I.C.O.S guidelines were used to structure the questions and the research topic as to attain clinical validity. The results of the research were filtered in accordance with the PRISMA checklist. Results: We identified 42 papers. After screening 27 papers were used to complete the analysis. Discussion: There is an increased interest towards the non-operative management of rectal cancer, as up to 25% of patients with preoperative radiochemotherapy have demonstrated complete pathological response (absence of tumor cells on the operative specimens). This information leads to the tantalizing idea that in some cases, surgery can be avoided. Unfortunately, there is a lack of quality data to support this view. Due to increased interest in this subject, an international database in which patients with w w therapy can be enrolled and monitored. Up to now, the database contains over 900 patients. Also, quality prospective trials are emerging. Conclusion: Even with all these recent efforts, the wide-use of this therapy is precluded due to the absence of a standardized evaluation of these patients in the follow-up period.

Introduction. The paramedian forehead flap is one of the best options for reconstruction of the median upper two-thirds of the face due to its vascularity, color, texture match and ability to resurface all or part of the reconstructed area. The forehead flap is the gold standard for nasal soft tissue reconstruction and the flap of choice for larger cutaneous nasal defects having a robust pedicle and large amount of tissue. Materials and Methods. We are reporting a clinical series of cutaneous tumors involving the nose, medial canthus, upper and lower eyelid through a retrospective review of 6 patients who underwent surgical excision of the lesion and primary reconstruction using a paramedian forehead flap. Results. The forehead flap was used for total nose reconstruction, eyelids and medial canthal reconstruction. All flaps survived completely and no tumor recurrence was seen in any of the patients. Cosmetic and functional results were favorable. Conclusions. The forehead flap continues to be one of the best options for nose reconstruction and for closure of surgical defects of the nose larger than 2 cm. Even though is not a gold standard, median forehead flap can be an advantageous technique in periorbital defects reconstruction.

Background and Objectives: The Mayer&ndash, Rokitansky&ndash, K&uuml, ster&ndash, Hauser syndrome is a congenital condition in which patients are born with vaginal and uterus agenesis, affecting the ability to have a normal sexual life and to bear children. Vaginal reconstruction is a challenging procedure for plastic surgeons. The aim of this study is to report our experience in the management of twelve patients with congenital absence of the vagina due to the MRKH syndrome. Materials and Methods: We performed a retrospective study on 12 patients admitted to the Plastic Surgery Department of the Clinical Emergency Hospital &ldquo, Prof. Dr. Agrippa Ionescu&rdquo, Bucharest, Romania, for vaginal reconstruction within a period of eleven years (January 2009&ndash, December 2019). All patients were diagnosed by the gynaecologists with vaginal agenesis, as part of the Mayer&ndash, Hauser syndrome. The Abbe`&ndash, McIndoe technique with an autologous skin graft was performed in all cases. Results: The average age of our patients was 20.16 (16&ndash, 28) years. All patients were 46 XX. The average surgical timing was 3.05 h (range 2.85&ndash, 4h). Postoperative rectovaginal fistula was encountered in 1 patient. Postoperative average vaginal length was 10.4 cm (range 9.8&ndash, 12.1 cm). Regular sexual life was achieved in 10 patients. Conclusion: Nowadays, there is no established standard method of vaginal reconstruction. In Romania, the McIndoe technique is the most applied. Unfortunately, even if the MRKH syndrome is not uncommon, less and less surgeons are willing to perform the procedure to create a neovagina.

Backround/Objective: The aim of investigation was to evaluate if there is a pattern regarding the anatomical location of the disease and type of surgery performed/surgical indication. Also a analysis was performed regarding the complication rate in two subgroups deriving from urban and rural environments. Methods: Data was obtained from the medical records of patients with CD and centralized. Tests of statistical analysis included the CHY-SQUARE test and the results were presented as a retrospective, longitudinal study. Results: The group was formed of 60 patients. Patients with ileocolic disease were frequently diagnosed with obstruction and benefited from an enterectomy with anastomosis. Patients with colonic disease were frequently diagnosed with perforation and benefited from colectomy and stomy. Patients from rural areas had a milder evolution when compared with patients from urban enviroments. Conclusions: Although most patients with CD eventually require surgery, the indication could be anticipated by recognition of the concept of clinical patterns, and type of surgery required could be predicted if the clinical aspect of the patient/disease were identified.

Introduction: Crohn disease (CD) has seen a steady increase in incidence over the years in Romania. Laparoscopy had a slow evolution as a feasible therapeutic option for patients with CD. Material and Method: The study is retrospective. The period on which the data was gathered spread over 8 years (01.01.2011-01.01.2019). Data was retrieved from three Clinical Hospitals in Bucharest, Romania Results: the preoperative diagnosis of an intestinal fistula (p = 0,02), sepsis (p = 0.01 ) or increased age should be regarded as a limitation for a laparoscopic approach in CD complications. Also in emergency settings an open approach should be the mainstay treatment (approach p = 0.000001). Conclusion: Laparoscopy is a feasible surgical option in the treatment of surgical complication in CD. In order to increase the safety of the intervention, correct selection of patients is important.

Goals To evaluate the indications of TAAP vs TEP in the treatment of unilateral inguinal hernia and the limitations of each technique using the experience of our clinic. Material and method The study is retrospective, extends over 4 years and includes patients with unilateral inguinal hernia operated using either TAAP or TEP technique. Results: We identified a number of 40 patients of which 25 were treated with the TAPP and 15 with the TEP technique. The mean age in the TAAP group was 42 years and 38 years in the TEP group. Mean surgery time for TAAP was 52 min; for TEP it was 62 min. Large inguinoscrotal hernias were operated with the TAAP technique. Conversion from TEP to TAAP was encountered in 2 cases, while conversion to open a hernia was encountered in 3 cases. No deaths were recorded in the follow-up time. Conclusions: Both TAAP and TEP are feasible surgical options to treat an inguinal hernia. The use of the TEP technique is limited by the size of the hernia defect while the TAAP technique has the advantage of larger intraoperative field, and an increased risk of injury to major abdominal organs.